GW1-2021-07311_Well Construction - GW1_20211006

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Vv t L L U U IU J 1 tt U U I I U IV M t U U M IJ I U VV-11 For Internal Use Only:
1.Well Cqntractor Information:
e � 14.WATER ZONES
Well ContractorNSme FROM TO DESCRIPTION
NC We Contractor Certification Number 3.OUTER CASING for multi cased wlls LINER`if a )!cable
r6 FROM TO DIAMETER THICKNESS MATrE�RI�AL
C r (C' '�,0 ft. ft. i in. S 4 -a c
Company Name �(C`�0��� INNER CASING OR TUBING `eothermalclosed-loo "
_ 2.Well Construction Permit#: �r FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,Col/W,State,,Parlance,etc.) ft• tt• in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM BEEN O DIAMETER SLOTSIZE I THICKNESS MATERIAL
Agricultural OM icipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) ' midential Water Supply(single) ft. ft. din:
_ Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
Ilri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft' b`f'- ft' QTLRtZ ?L 01A7
Monitoring (-Recovery ft. ft. 54tID '?
Injection Well: ft. ft.
Aquifer Recharge ElGroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery [3SalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
_i Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addit Iona['sheets if necessar
Geothermal(Heatin Cooling Return) 0Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soii/rock type,grain size,etc.
© ft. 075 ft. 0.6
4.Date Well(s)Completed: Well ID# aIL5 ft. 40 ft. i5; al
5a.Well Location: ft 3(,5 ft' 4e.
mrc_(nta�� �anS ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Ul.n i on G rwe C.Ilweh 'I id. ft. ft
Physical ft. fL__Address,City,and Zip �J Q Gpd
1 (`cSUt'1 %tq�NR�A3l PQfce( (0� 21..REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certification:`
N W , Jb,,wV //-
6.Is(are)the well(s)2<ermanent or OTemporary Signature of Certified well Contractor Date
By signing this farm,l hereby certify that the wen(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Eyes or 621'1110 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thata
if this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair underA21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ylO� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths if different(example-3@200'and 2@/00D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing,use"+' l 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1-0 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
D above, also submit one copy of!this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servici Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (P Method of test: O t K+ 24c. For Water Supply & Inieetibn Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: f4 T 11 1 Amount: completion of well construction)to the county health department of the county
where constructed.
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